Care Prioritizer: Making Veteran Health Care Priority One
Interview with
Michael J. Kussman, MD
Under Secretary for Health
Veterans Affairs
Brigadier General Michael J. Kussman, M.D., (U.S. Army, Ret.) was confirmed by the U.S. Senate as under secretary for health for the Veterans Health Administration (VHA) on May 25, 2007. As under secretary, Kussman leads the nation’s largest integrated health care system. He previously served as acting under secretary for health and principal deputy under secretary for health.
As under secretary for health, he directs a health care system with an annual budget of approximately $37.3 billion, which employs more than 198,000 health care professionals and support staff at more than 1,400 sites of care, including hospitals, community and facility-based clinics, nursing homes, domiciliaries, readjustment counseling centers and various other facilities. Kussman oversees the delivery of health care to more than 5.5 million veterans throughout the United States. In addition to its health care mission, VHA is the nation’s largest provider of graduate medical education and a major contributor to medical and scientific research. More than 100,000 volunteers, 92,000 health profession trainees, and 25,000 affiliated medical faculty members are integral parts of the VHA community.
Kussman is a native of Troy, N.Y. He earned his undergraduate and medical degrees from Boston University, receiving the M.D. in 1968. He earned a master’s degree in management from Salve Regina University in 1994. Kussman began his military career in 1970, serving with the 7th Infantry Division in Korea. He left active duty in 1972 to resume medical training and complete his residency at the Joslin Clinic in Boston. From 1974 to 1979, He worked in private practice in Pittsfield, Mass.
In 1979, Kussman returned to active duty at Tripler Army Medical Center in Honolulu, Hawaii, serving as chief of internal medicine. He later served as division surgeon for the 25th Infantry Division in Hawaii. From 1984 to 1988, Kussman served as chief of the Department of Medicine at Brooke Army Medical Center in San Antonio, Texas. He completed his tour there as deputy commander for clinical services.
Kussman became the Army Surgeon General’s chief consultant in internal medicine and governor for the Army Region of the American College of Physicians in 1988. He commanded Martin Army Community Hospital at Fort Benning, Ga., from March 1993 to August 1995, and later commanded the Walter Reed Health Care System in Washington, D.C., where he was promoted to brigadier general.
Following his tour at Walter Reed, Kussman served as commander of the Europe Regional Medical Command, command surgeon for U.S. Army Europe, and TRICARE lead agent for Europe. He was responsible for Army health care throughout Europe, the Middle East and Africa.
Kussman is a graduate of the Army War College and an honor graduate of the Command and General Staff College. His military decorations include the Distinguished Service Medal (the highest award given in peace time), Legion of Merit with three oak leaf clusters, Defense Meritorious Service Medal and the Order of Military Medical Merit. Kussman received the prestigious “A” designator from the Army Surgeon General, which identifies professorial rank, and the Laureate Award from the American College of Physicians/American Society of Internal Medicine, and was selected as a Master of the College. He is board certified in internal medicine and serves on the faculty of the Uniformed Services University of Health Sciences.
Dr. Kussman was interviewed by MMT Editor Jeff McKaughan
Q: Can we start with a brief overview of the VA health care system, perhaps in context of comparison of this time last year to today?
A: Our most important mission of providing health care to the nation’s veterans has not changed. What has changed is some aspects of how we carry out that mission. For example, the number of patients we serve continues to increase—up to a record 5.5 million last year. In response, we have further expanded our system so that it now includes 215,000 employees, 153 hospitals, 881 clinics and 229 readjustment counseling centers. I’m pleased to note that the high quality of our care continues even as we grow. A recent book by an author who also works at a Washington think tank was titled Best Care Anywhere: Why VA Health Care is Better than Yours. We’re proud of that, and we want to be sure that all veterans who are eligible for and need our care are able to get it.
With that goal in mind, VHA has begun several new initiatives in the last year. For now, I’ll mention just two as examples, beginning with the new Combat Veteran Call Center Initiative. Starting May 1, we’ll call OEF/OIF veterans by telephone to inform them about VA services and make sure they’re getting the services they want and need from us. First, we’ll be contacting 17,000 veterans identified as potential Care Management candidates. Then we’ll contact all 550,000 OEF/OIF veterans who have been discharged from the military and who are not current VHA users. The calls will be made through a contractor using a series of prepared scripts. Of course, this initiative is sure to create new responsibilities—and new patients—for us. I welcome the work … and the opportunity to help many, many more veterans get the help they need and deserve.
Another example of success in patient care is our new suicide prevention hotline, which began operating last summer in Canandaigua. More than 37,000 veterans have called the hotline since it’s been open for business—that’s thousands of veterans we’ve helped every month. In more than 725 cases, the veteran on the other end of the line was clearly in danger of harming himself or herself—and harming others. That’s 725 lives saved. It’s the kind of return on investment we’re looking for.
Q: Are the biggest challenges faced by the VA for the next 12 months basically the same as they were 12 months ago?
A: One of our highest priorities is to ensure that veterans returning from service in Operation Enduring Freedom and Operation Iraqi Freedom receive everything they need to make their transition back to civilian life as smooth and easy as possible. We will do what we must to provide them with timely benefits and services, to give them complete information about the benefits they have earned through their courageous service, and to implement streamlined processes free of bureaucratic red tape.
We will provide timely, accessible and high-quality medical care for those who bear the permanent physical scars of war as well as compassionate care for veterans who suffer from less visible but equally serious and debilitating mental health issues, including traumatic brain injury [TBI] and post-traumatic stress disorder [PTSD]. Our treatment of those with mental health conditions will include veterans’ family members who play a critical role in the care and recovery of their loved ones.
President Bush’s top legislative priority for VA is to implement the recommendations of the President’s Commission on Care for America’s Returning Wounded Warriors [Dole-Shalala Commission]. The commission’s report provides a powerful blueprint to move forward with ensuring that service men and women injured during the global war on terror continue to receive the health care services and benefits necessary to allow them to return to full and productive lives as quickly as possible. VA has initiated studies to determine appropriate payment levels for quality of life, transition assistance and loss of earnings. The next step is for Congress to pass the president’s legislation, which will modernize the disability compensation system. VA is working closely with officials from DoD on the recommendations of the Dole-Shalala Commission that do not require legislation to help ensure veterans achieve a smooth transition from active military service to civilian life.
For example, VA and DoD signed an agreement in October 2007 to provide federal recovery coordinators to ensure medical services and other benefits are provided to seriously-wounded, injured and ill active duty servicemembers and veterans. VA has already hired the first recovery coordinators, in coordination with DoD, and they are located at Walter Reed Army Medical Center, Bethesda National Naval Medical Center, and Brooke Army Medical Center. They will coordinate services between VA and DoD and, if necessary, with private-sector facilities, while serving as the ultimate resource for families with questions or concerns about VA, DoD, or other federal benefits to which they may be entitled.
Q: With veterans’ health care costs expected to rise, at a personal level as well as a percentage of the budget, are there things that we should be doing that perhaps not enough emphasis is being placed on right now to prepare for these issues?
A: The resources VA is requesting for its medical care program will allow us to strengthen our position as the nation’s leader in providing high-quality health care. VA has received numerous accolades from external organizations documenting the department’s leadership position in providing world-class health care to veterans. For example, our record of success in health care delivery is substantiated by the results of the December 2007 American Customer Satisfaction Index [ACSI] survey. Conducted by the National Quality Research Center at the University of Michigan Business School and the Federal Consulting Group, the ACSI survey found that customer satisfaction with VA’s health care system was higher than the private sector for the eighth consecutive year. The data revealed that patients at VA medical centers recorded a satisfaction level of 83 out of a possible 100 points, or six points higher than the rating for care provided by private-sector health care providers.
In December 2007 the Congressional Budget Office [CBO] issued a report highlighting the success of VA’s health care system. In this report, entitled, the CBO identified organizational restructuring and management systems, the use of performance measures to monitor key processes and health outcomes, and the application of health IT as three of the major driving forces leading to high-quality health care delivery in VA. In October 2007, the Institute of Medicine released a report, “Treatment of PTSD: An Assessment of The Evidence,” which states VA’s use of exposure-based therapies for the treatment of PTSD is effective. This confirms the department’s own conclusions and bolsters our efforts to continue to effectively treat veterans of the global war on terror who are suffering from PTSD and other mental health conditions.
These external acknowledgments of the superior quality of VA health care reinforce the Department’s own findings. We use two primary measures of health care quality—our clinical practice guidelines index and our prevention index. These measures focus on the degree to which VA follows nationally recognized guidelines and standards of care that the medical literature has proven to be directly linked to improved health outcomes for patients.
Q: Sticking with costs for a minute, how does your FY09 budget estimate look in comparison with your needs both at the funds needed to operate as well as enhance services for new programs and construction?
A: The president’s 2009 request includes total budgetary resources of $41.2 billion for VA medical care, an increase of $2.3 billion over the 2008 level and more than twice the funding available at the beginning of the Bush Administration. Our total medical care request is comprised of funding for medical services [$34.08 billion], medical facilities [$4.66 billion], and resources from medical care collections [$2.47 billion]. During 2009, we expect to treat about 5,771,000 patients. This total is nearly 90,000, or 1.6 percent, above the 2008 estimate. Our highest priority patients [those with service-connected disabilities or those with low incomes] will comprise 67 percent of the total patient population in 2009, but they will account for 84 percent of our health care costs.
We expect to treat about 333,000 veterans in 2009 who served in Operation Enduring Freedom and Operation Iraqi Freedom. This is an increase of 40,000, or 14 percent, above the number of veterans from these two campaigns that we anticipate will come to VA for health care in 2008, and 128,000, or 62 percent, more than the total in 2007. In 2009 we are requesting nearly $1.3 billion to meet the needs of the 333,000 veterans with service in Operation Enduring Freedom and Operation Iraqi Freedom whom we expect will come to VA for medical care. This is an increase of $216 million, or 21 percent, over our resource needs to care for these veterans in 2008.
The department’s resource request includes $3.9 billion in 2009 to continue our effort to improve access to mental health services across the country. This is an increase of $319 million, or 9 percent, above the 2008 level. These funds will help ensure VA continues to realize the aspirations of the president’s New Freedom Commission Report, as embodied in VA’s Mental Health Strategic Plan, to deliver exceptional, accessible mental health care. The department will place particular emphasis on providing care to those suffering from PTSD as a result of their service in Operation Enduring Freedom and Operation Iraqi Freedom. An example of our firm commitment to provide the best treatment available to help veterans recover from these mental health conditions is our increased outreach to veterans of the global war on terror, as well as increased readjustment and PTSD services. Our strategy for improving access includes increasing mental health care staff and expanding our telemental health program that allows us to reach about 20,000 additional patients with mental health conditions each year.
VA’s medical care request includes nearly $1.5 billion to support the increasing workload associated with the purchase and repair of prosthetics and sensory aids to improve veterans’ quality of life. This is $134 million, or 10 percent, above the funding level in 2008. This increase in resources for prosthetics and sensory aids will allow the department to meet the needs of the growing number of injured veterans returning from combat in Afghanistan and Iraq.
VA’s medical care request includes nearly $1.5 billion to support the increasing workload associated with the purchase and repair of prosthetics and sensory aids to improve veterans’ quality of life. This is $134 million, or 10 percent, above the funding level in 2008. This increase in resources for prosthetics and sensory aids will allow the department to meet the needs of the growing number of injured veterans returning from combat in Afghanistan and Iraq.
Q: There is a documented shortage—forecasted to become even worse—in certain health care professions, nursing for example. What is the VA doing to attract and retain key professionals at the provider level? And, as a follow-on, do you see the VA using more outsourced services in the future?
A: There is a growing realization that the supply of appropriately prepared health care workers in this country is inadequate to meet the needs of a growing and diverse population. This shortfall will grow exponentially over the next 20 years. This situation exists for various reasons. Enrollment in professional schools is not growing fast enough to meet the projected future demand for health care providers. The American Association of Colleges of Nursing has reported that more than 42,000 qualified applicants were turned away from nursing schools in 2006 because of insufficient numbers of faculty, clinical sites, classroom space and clinical mentors. The availability of academic programs to provide employees to meet qualification standards in other health care occupations is being experienced in many other health care occupations.
More than 100,000 health professions trainees come to VA facilities each year for clinical learning experiences. Many of these trainees are near the end of their education or training programs and become a substantial recruitment pool for VA employment as health professionals. An annual VHA Learners’ Perceptions Survey shows that, overall, following completion of VA learning experiences, trainees were twice as likely to consider VA employment as before the experience. This demonstrates that many trainees were not aware of VA employment opportunities or the quality of VA’s health care environment before VA training but became considerably more interested after VA clinical experiences.
An informal survey conducted of all VA facilities in 2007 revealed that 74 percent of the 800 psychologists hired over the last three years received some training in professional psychology through VA. This year, the Offices of Academic Affiliations and Patient Care Services significantly expanded VA’s psychology training programs in anticipation of the ongoing need for additional VA psychologists.
VHA Health Care Retention & Recruitment Office has produced a new recruitment brochure titled “From Classroom to Career” that is targeted at and distributed to VA trainees. The Office of Academic Affiliations in VA Central Office emphasizes recruitment of trainees in interactions with education leaders in the VA facilities.
In an effort to initiate proactive strategies to aid in the shortage of clinical faculty, VA launched the VA Nursing Academy to address the nationwide shortage of nurses. The purpose of the academy is to expand the number of nursing faculty in American nursing schools, increase student nursing enrollment by 1,000 students, increase the number of students who come to VA for their clinical learning experience, and promote innovations in nursing education and clinical practice. Four partnerships were established with nursing schools for the 2007–2008 school year. Four additional partnerships will be selected each year in 2008 and 2009 for a total of 12 partnerships.
VA’s Travel Nurse Corps is an exciting new program establishing an internal pool of registered nurses who can be available for temporary, short-term assignments at VA medical centers throughout the country. The VA Travel Nurse Corps meets nurses’ needs for travel and flexibility while meeting VA medical center needs for temporary top-quality nurses. The goals of the program are to maintain high standards of patient care quality and safety; reduce the use of outside supplemental staffing, improve recruitment of new nurses into the VA system; improve retention by decreasing turnover of newly recruited nurses, provide alternatives for experienced nurses considering leaving the VA system; and to establish a potential pool of registered nurses for national emergency preparedness efforts. The VA Travel Nurse Corps Program may also serve as a model for an expanded multidisciplinary VA Travel Corps in the future.
Student programs have been instrumental helping meet VA work force succession needs. These programs include the VA Learning Opportunities Residency [VALOR] Program, the Student Career Experience Program [SCEP], and the Hispanic Association of Colleges and Universities Internship Program [HACU]. VALOR is designed to attract academically successful students of baccalaureate nursing programs and pharmacy doctorate programs to work at VA. VALOR offers a paid internship and gives the honor students the opportunity to develop competencies in their clinical practice in a VA facility under the guidance of a preceptor.
In response to the success of the VALOR program for nurses, the pharmacy component was added in 2007 to address VA’s need for pharmacists. SCEP and HACU offer students work experience related to their academic field of study. VHA’s goal is to actively recruit these students for permanent employment following graduation. VA National Database for Interns is a newly designed database developed to track students in VA internship and student programs to create a qualified applicant pool.
The Graduate Health Administration Training Program [GHATP] provides practical work experience to students and recent graduates of health care administration master’s degree programs. GHATP residents and fellows are competitively selected and on successful completion of the programs are eligible for conversion to VA health system management positions. The Technical Career Field program is an entry level program designed to fill vacancies in technical career fields [budget, finance, human resources, engineering, etc] where shortages are predicted and VA-specific knowledge is critical to success. Recruitment is focused on colleges and universities. Each intern is placed with an experienced preceptor in a VHA facility. The program is designed to be flexible based on the changing needs of the work force. Annually, the target positions and number of intern slots are determined based on projected work force needs.
Q: Are there examples of where the VA has been an innovator in bringing new medical technologies to the patient? What are some of the most recent technological advancements that have improved patient care?
A: For more than 80 years, VA research has been a valuable investment with remarkable and lasting returns for veterans and the nation as a whole. Many people are familiar with the awards won by VA investigators—three Nobel prizes, six Lasker awards, and many others. But what is more important is the large number of treatments and procedures that have been developed and effectively proven to work by VA investigators. VA research has taken special advantage of its connection to clinical care and is replete with examples of how it has improved care, including:
- Developing numerous advances in prosthetics, including better-fitting and lighter artificial limbs, prosthetics that can sense, artificial hands that are capable of very fine motion, a biomechanical foot, and the Seattle foot—a great early example of these advances;
- Pioneering understanding of and treatment for post-traumatic stress disorder, including exciting new treatment advances proving the effectiveness of prolonged exposure therapy and a drug to significantly reduce trauma nightmares and other sleep disturbances in PTSD;
- Identifying genes associated with Alzheimer’s disease and premature aging;
- Laying the groundwork for the development of the computerized axial tomography scan;
- Pioneering research efforts leading to new home dialysis techniques;
- Developing the nicotine patch and other therapies to help smokers quit;
- Developing the cardiac pacemaker and many other advances for abnormalities of heart rhythm, high blood pressure, and coronary artery disease; and
- Developing a system that decodes brain waves and translates them into computer commands that allow tetraplegics to perform simple tasks like turning on lights and opening e-mails by using only their minds.
VA’s Cooperative Studies Program deserves special mention. It has received national media attention for its groundbreaking work improving treatment for a host of critical medical conditions, including: A series of studies that established the cornerstone for treatment of hypertension; One of the first studies to ascertain the long-term effects of coronary artery bypass surgery; An investigative study on the use of cortisone to treat patients with septic shock; A landmark study that showed aspirin reduces deaths and heart attacks in patient with unstable chest pain; A vaccine for shingles; New innovative drugs and therapies to treat PTSD; and A study that showed balloon angioplasty plus stenting did little to improve outcomes for patients with stable coronary artery disease who also received optimal drug therapy and underwent lifestyle changes.
Q: How big of a role does the VA play in funding as well as actually performing key medical research in establishing cures and treatments for illnesses and injuries?
A: VA is requesting $442 million to support our medical and prosthetic research program. Our request will fund nearly 2,000 high-priority research projects to expand knowledge in areas critical to veterans’ health care needs, most notably research in the areas of mental illness [$53 million], aging [$45 million], health services delivery improvement [$39 million], cancer [$37 million], and heart disease [$33 million].
One of our highest priorities in 2009 will be to continue our aggressive research program aimed at improving the lives of veterans returning from service in Operation Enduring Freedom and Operation Iraqi Freedom. The president’s budget request for VA contains $252 million devoted to research projects focused specifically on veterans returning from service in Afghanistan and Iraq. This includes research in TBI and polytrauma, spinal cord injury, prosthetics, burn injury, pain and post-deployment mental health. Our research agenda includes cooperative projects with DoD to enhance veterans’ seamless transition from military treatment facilities to VA medical facilities, particularly in the treatment of veterans suffering from TBI.
The president’s request for research funding will help VA sustain its long track record of success in conducting research projects that lead to clinically useful interventions that improve the health and quality of life for veterans as well as the general population. Recent examples of VA research results that have direct application to improved clinical care include the use of a neuromotor prosthesis to help replace or restore lost movement in paralyzed patients, continued development of an artificial retina for those who have lost vision due to retinal damage, use of an inexpensive generic drug [prazosin] to improve sleep and reduce trauma nightmares for veterans with PTSD, and advancements in identifying a new therapy to prevent or slow the progression of Alzheimer’s disease.
In addition to VA appropriations, the department’s researchers compete for and receive funds from other federal and non-federal sources. Funding from external sources is expected to continue to increase in 2009. Through a combination of VA resources and funds from outside sources, the total research budget in 2009 will be almost $1.85 billion.
Q: Over recent years numerous reports have talked about better transitions from the Military Health System to the VA system as well as the use of electronic medical records. How would you characterize the state of those issues and the expected progress over the next 12 months—starting first with the transition of patients from the MHS to VA?
A: VHA has long emphasized the importance of a personalized continuum of care for servicemembers. Our commitment extends beyond the initial transition across systems of care to ensure services continue to be provided to these individuals as veterans, and to their family members, who are essential to the recovery and rehabilitation of these injured warriors.
To ensure every veteran or servicemember receives the care and benefits they deserve, VA has created a case management program for Operation Enduring Freedom/Operation Iraqi Freedom [OEF/OIF] veterans. The VA/DoD Federal Recovery Coordination Program further provides needed assistance and support for veterans and servicemembers with serious injuries or illnesses. VA’s provision of both inpatient and outpatient rehabilitation services in locations across the country is designed to meet the short- and long-term needs of veterans with serious injuries, including polytrauma, traumatic brain injury, spinal cord injury and mental health needs. These overlapping strategies of case management and coordination of rehabilitative care enable VA to adapt to the needs of our returning veterans and operating a system capable of providing lifelong care to them. VA has pursued outreach on multiple levels to see that our veterans, particularly those with severe injuries or illnesses, can access our system and receive the care they have so bravely earned. As I mentioned earlier, the new VA Combat Veteran Call Center will ensure that all OEF/OIF veterans are aware of the health care and benefits available to them.
We also are improving the sharing of medical information between VA and the Department of Defense to develop a seamless health information system. Our long-term goal is to ensure appropriate beneficiary and medical information is visible, accessible and understandable through secure and interoperable information technology. The senior oversight committee [a joint VA/DoD committee] has approved initiatives to ensure health and administrative data are made available and are viewable by both agencies. DoD and VA are securely sharing more electronic health information than at any time in the past. In addition to the outpatient prescription data, outpatient and inpatient laboratory and radiology reports, allergy information, access to provider/clinical notes, problem lists, and theater health data have recently been added. In December 2007, DoD began making inpatient discharge summary data from Landstuhl Regional Medical Center immediately available to VA facilities. The plan for information technology support of a recovery plan for use by federal recovery coordinators was approved in November 2007. A single web portal to support the needs of wounded, ill or injured servicemembers, commonly referred to as the eBenefits Web Portal, is planned based on VA’s successful eVet Website.
Q: And your view of the electronic health record programs?
A: VHA leads the private health care sector in the areas of electronic medical records, overall patient satisfaction and effective negotiations with pharmaceutical companies. VA and DoD have made significant progress toward the development of interoperable electronic health record systems. Since 2002, DoD has transferred available electronic records on approximately 4.3 millions servicemembers that have separated from active duty. DoD transferred these records to a jointly developed secure repository, known as the Federal Health Information Exchange [FHIE], where the records are available for viewing by VHA clinicians treating these veterans and VBA staff adjudicating disability claims. DoD also has transferred pre- and post-deployment health assessment and post-deployment health reassessment forms in electronic format on over 880,000 patients. These forms are also available for viewing in FHIE.
In 2004, VA and DoD began sharing current electronic health data in viewable format bidirectionally through the Bidirectional Health Information Exchange. At present, VA and DoD have increased this data exchange to now include outpatient medication, allergy information, laboratory results, radiology reports, ambulatory encounter notes, problem lists, procedures and discharge summaries. These data are exchanged on shared patients that receive health care from both VA and DoD facilities. The data are available at every DoD military treatment facility and VA medical center, including key facilities treating wounded warriors, such as Walter Reed and Brooke Army Medical Centers, Bethesda National Naval Medical Center, and Landstuhl [Germany] Regional Medical Center. DoD also is sending clinical theater information electronically in order to address issues related to battlefield injuries.
In support of our most seriously ill and injured patients, DoD is sending radiology images and scanning the entire medical record at these facilities and sending them to the four polytrauma rehabilitation centers that are receiving these patients for recovery and rehabilitation.
Q: Any closing thoughts?
A: First, I thank you for your interest in veterans' health care. I believe it is a privilege to care for the men and women who have served in our military. I have told VHA employees that my priorities for the future are putting patient care first, practicing progressive leadership, promoting improved business processes and producing meaningful performance measures.
However, not all priorities are created equal. Patient care is first and foremost, and we are determined to provide veterans with the best care available anywhere, which they have earned with their service and sacrifice. ♦